Test Your Knowledge CHF/ Cardiac Inflammation

A: CHF 1. You have taught a patient with CHF about low sodium diets. On return to the clinic, he/ she has gained 6 lb over the last 4 days. The patient insists they are following the diet. What would you do next? State your rationale. 2. What happens to heart chamber pressures in CHF? In the CHF patient, what does JVD represent? chamber pressure increases with CHF, JVD represents increased in right sided atrial pressure 3. What is Lasix and Vastotec? How would using these together benefit the patient with CHF? As the nurse, how would you monitor for effectiveness in these drugs? vasoten (ace inhibitor) can vasodilate, decreases angiotensin and uptake of sodium, approaching fluid balance in 2 different ways. Ask about dyspnea and fatigue to see if they have improved to know if med is working. 4. Review the following medications: Morphine, Valium, Intropin, Tridil. What is the therapeutic use of these drugs in the patient with CHF? Intropin-dopamine , tridil-nitroglycerin. Dopamine increases Bp, usually given to people with severe Hypotension. Dont give in CHF. Valium is just antianxiety med, do not give for CHF. Morphine reduces preload to reduce workload of heart and anxiety. Give to patient with acute CHF and are anxious about getting enough air. Nitroglycerin vasodilates, no antianxiety properties, can be used in CHF but is not drug of choice. 5. What is Nipride? How is it used in the patient with CHF? What is a major side effect that would be reason for the nurse to titrate the dose? Give rationale. Powerful vasodilator used for management of acute CHF. IV drug. Monitor blood pressure carefully. One of the indications to titrate (adjust dose of) nitride is decrease BP. Systolic has to be 90 or greater and MAP greater than 60 for adequate renal perfusion (risk for ischemic changes) 6. Develop a teaching plan for the patient with CHF. What key things should you teach the patient with CHF? Provide rationale. Daily weights and if you gain more than 3 pounds over 2 days. Weigh same time, same clothes, same scale. Low sodium diet and hidden sources of sodium. A little about the pathology. Meds, activity rest, etc.

7. What is preload? What do you want to do to preload in the patent with CHF? State rationale. What nursing action can you take to accomplish your goal? Amount of stretch heart will do before contraction. The higher the preload the higher the afterload. Increased afterload increases workload of heart. So if you can manage preload you can manage afterload. Put patient in semi fowlers (45 degrees head of bed), 8. How does potassium affect Digoxin? IF taking Digoxin, when should the patient contact the doctor? What is Hydrodiuril? How does this medication affect potassium? What are some evidences of Dig. Toxicity? Answer below Instruct to take pulse before they take digoxin. If its less than 60 check with doctor before taking it, dont just not take med without consulting doctor. Any diuretic, even potassium sparing still makes body loose potassium. Teach for dig toxicity- nausea and comiting, seeing yellow hallows. Teach Signs of worsening CHF because this means med isnt being effective- decompensation-worsening dyspnea and SOB. 9. What is Dobutrex, Cardizem and Captopril? Which of these are used in the client with CHF? Which one is for long term therapy? What should you teach the patient regarding these drugs? Dobutrex-decreases preload. Cardizem- controls heart rate, calcium channel blocker, Captopril-ace inhibitor, diuretic effect. Use dobutrex and captopril the most for CHF. Long term therapy is Captopril. 10. What is Coreg? Initially what does this drug do to the symptoms of CHF? What are major side effects of this drug that require immediate notification of the MD? State rationale. Used for management of CHF. Decreased heart rate, vasodilates, improves flow to kidneys. Decreases blood pressure. Since they already have weak heart, monitor BP. If it gets below 90 contact doctor so we can protect renal perfusion. 11. What is Natrecor? How does It work on a physiolgocal basis to improve symptoms of CHF? Used for acute decompensated CHF. B: Infective/ Inflammatory Heart Disease 1. What is infective endocarditis? What is the most common cause? What healthcare practices can contribute to the development of this disease? Most common cause is strep. Ask patient if they have had recent dental work or sore throat. Dental work can knick patients gum and become a portal for bacteria. Dental.

2. What are some assessment findings which are specific to infective endocarditis? Osslers nodes-painful, purple or red, small lesions found on toes or fingertips. James way lesions-flat painless, ecchymosis, found on palms and soles of feet. 3. One of the risks of infective endocarditis is embolization to the kidney. What would be a evidence that this is happening? What should you, as the nurse, do? Sudden onset of flank pain. Contact doctor, maintain fluid balance. Doctor may want BUN and creatinine. 4. You are caring for a patient with pericarditis. He asks you why he is getting so many EKGs What do you plan on telling him? What drug is best to decrease pain from inflammation in the patient with pericarditis? Inflammation of pericardial sack. Puts pressure on heart that can cause cardiac tamponade which is an emergent situation because it is squeezing on heart causing difficulty of blood to get into heart and out. Do multiple EKGS, you would expect to find generalized changes across EKG, Continue to monitor, do multiple EKGs to see if problem is resolving. Motrin is best to decrease pain and inflammation, give 800 mg. 5. How would you assess for a pericardial friction rub? Sound like rubbing hands together. Position patient in leaning forward or on their left. Review use of diaphragm and use of bell. 6. What is pulsus paradoxus? How do you assess for this disorder? What is the normal level for pulsus paradoxus and and what level is it considered abnormal according to your book? What is the significance of JVD in the patient with pearicarditis? Decreased or absence systolic BP with inspiration. Example is cardiac tamponade. Less than 10 change between hearing is normal, greater than 10 is abnormal. Not isolated hypertension (in elderly). JVD youll see with increased atrial pressure which means that heart is being squeezed down on so heart cannot fill effectively which can cause cardiac tamponade. In normal pericarditis there is no squeezing but high pressure can cause the back up of fluid causing cardiac tamponade. 7. Your patient with pericarditis has acute pain from inflammation. What non collaborative nursing action can you take to reduce the pain? State rationale. Reduce risk by pericardial window to let fluid out which markedly decreases cardiac tamponade. Any patient with pericarditis one of main goals is to keep patient at rest to conserve oxygen and workload of heart. 8. What is rheumatic fever? What is the most common etiology? What musculoskeletal problems can occur with this disorder? Acute inflammatory condition of heart. Can be latent, had as kid but can show signs and symptoms as adult. Signs is polyarthritis, nodules. Typically affects valves of heart

9. What is the long term management regime for a patient with rheumatic fever? Long term antibiotics for 4 to 5 years. Do blood cultures always before antibiotics if both are offered. 10. In valve disorders, what is stenosis? Regurgitation? What happens to blood flow in each of these? What happens to cardiac output in both of these? What happens to circulating oxygen? What is a common indicator of lack of oxygen to the tissues? Stenosis is stiff valves, blood flows forward but not enough and regurgitation is weak and open valves where blood can flow backward. Mitral valve stenosis causes blood to back up in left atrium and ultimately the lungs. Mitral is typically the most common one involved. Review the other valves. 11. For each of these disorders, discuss what happens to blood flow and symptoms you should observe for: Mitral stenosis, Aortic stenosis, Tricuspid stenosis 12. What type of blood flow do you have with valvular disorders? What first line drug is commonly used in valvular disorders? State rationale. 13. What is the difference between a biological (pigskin) valve and a mechanical valve? Consider life of the valve, age of the client and therapeutic management requirements of each. Pigskin valve doesnt last as long Metal valve is long term, but have to be on anticoagulant (Coumadin) for rest of life. If child bearing woman you cant take Coumadin. 14. For the patient with cardiomyopathy, what associated disorder is common in all three types of cardiomyopathies? What do you plan on teaching the client regarding this associated disorder? Structural changes in heart. Dilated, restrictive and hypertrophic are three types and all involve some degree of CHF. Do CHF teaching. Dilated-overall decrease pressure, needs a lot of force to get blood out. Related to infection. Restrictive- develop fibers in muscle. Not considered cardiac tamponade yet. Hypertrophic- increase in muscle mass that starts to invade chamber, can do surgery to remove part of muscle mass and relieve pressure off heart but it is considered major surgery. 15. There are three types of cardiomyopathies. What are they? What changes occur in the heart with each? Which one is associated with sudden cardiac death? Which one is the patient most likely to be recommended for a cardiac transplant? See turbulent flow that puts as major risk for clotting. 16. What happens to blood flow in patients with cardiomyopathy? What is the therapeutic advantage to the use of heparin in patients with cardiomyopathy?

-Know key lab values in CHF -CHF-heart is unable to pump adequately. You can have right sided or left sided failure, but over time one will lead to the other and youll have both. Right sided most common cause is pulmonary hypertension (increased pressure in lungs, most common cause is stiffening in lungs caused by damage from smoking or asthma). Left sided failure most common is Hypertension (the silent killer) and myocardial infraction (left side is more susceptible to MIs). As tissue dies from MI, it is replaced with scar tissue. Remodeling (alteration in the way the heart looks as tissue is replaced with scar tissue) occurs and you start to see enlargement in area and decrease in function. Eventually patient develops CHF. Put patient on medications like vasodilators to decrease workload of heart so the whole remodeling process is minimized to help reduce CHF. -Signs of right sided failure-jugular vein distention (caused by right side atrial increased presuure), leg edema (not only a symptom of right sided failure so pick JVD for right failure over leg edema), decreased appetite and nausea (gut is engorged with blood causing decreased motility), SOB with activity or rest, fatigue. Assess ability to do ADLs -Signs of left sided- Pulmonary congestion, dyspnea when they are sleeping (patients start increasing pillows to keep head up to help with breathing-pillow orthopnea), increased voiding, pleural effusion (fluid in pleural space, decreases lung expansion which decreases oxygen intake), Ischemic pain in heart (pain due to decreased oxygenation). -Labs for heart failure- BNP, EKG-ventricular hypertrophy, cardiac cath-change in pressure, echo increased chamber pressure, Chest x-ray-cardiac enlargement, decrease in ejection fraction. -Assessment- hear PMI (apical pulse) lower (around ribcage, normal is 4 or 5, enlarged heart is 6 or 7), ask ADLs, etc. -MEDS- diuretic, lasix and potassium sparing. Lasix use cautiously in known renal disease. K sparing-still loose potassium, just not as much (spiralactone). Digitalis increases contractile force of heart. Lasix causes potassium to drop (enhances digoxin). -Patient teaching- believe patient (if patient is gaining weight but says he is following diet start checking patient knowledge or hidden levels of sodium in canned foods, teach patient to rinse off canned vegetables), Make it on level that patient can understand (5 th grade level), Make it applicable to them (watch words like may because its not concrete).

-Nursing diagnosis- it is what you see that is actual (dont put at risk for?) #1- assess sodium, start talking with them about label reading and maybe ask to bring in canned foods, talk about hidden sodium #2- chamber pressure increases with CHF, JVD represents increased in right sided atrial pressure #3-vasoten (ace inhibitor) can vasodilate, decreases angiotensin and uptake of sodium, approaching fluid balance in 2 different ways. Ask about dyspnea and fatigue to see if they have improved to know if med is working. -do blood cultures before starting antibiotics.